How to Use the CMS Approved Audit Issues as Compliance Guidance for Your Medical Practice
While it is impossible to pinpoint the exact areas that Recovery Audit Contractors (“RACs") will target when reviewing medical bills sent to Medicare, each regional RAC is required to post its current “issues under review” and disclose to the public the specific codes and/or procedures currently being audited by automated reviews (where no medical record is involved in the review).
For instance, the “issues under review” identified by Region A - Diversified Collection Services (which audits New York and New Jersey, among other states) are:
• IV Hydration
• Bronchoscopy services
• Blood transfusions
• Untimed Codes
• Neulasta: J2505; injection, Pegfilgrastim, 6mg
• Once In A Lifetime codes
• Newborn/Pediatric codes (i.e. newborn pediatric codes Billed for patients exceeding age limits)
• New patient visits
• Duplicate claims - Part B only
• Global billing of radiology or diagnostic tests in the facility setting
• Add-on codes
If your medical practice provides services that are identified as “issues under review,” the first step in any internal review and self-audit is to have the practices medical biller(s) and performing physician(s) review: (a) the applicable local coverage determinations (“LCDs”) and (b) the “issue description” and “issue references” disclosed with the specific “issue under review.” In most cases, the practice can easily correct the “issue” being audited by using an alternate code, submitting claims that are more detailed and/or limiting the services to allowable: beneficiaries, duration, frequency or levels.
